Prevalence and determinants of depression among pharmacy students enrolled in a newly implemented pharmd curriculum in Egypt: a cross-sectional study | BMC Psychology

Our study revealed a considerable prevalence of depression among Egyptian pharmacy students and identified key determinants contributing to their mental health challenges. Among the participants, 40.5% exhibited borderline to moderate depression, while 24.7% displayed significant depressive symptoms. These findings are consistent with previous research reporting high levels of psychological distress among healthcare students, underscoring the need for enhanced mental health support within academic settings [14,15,16]. For instance, an Iraqi study found that 45.9% of healthcare students exhibited depressive symptoms, with an additional 24.8% showing borderline levels [17]. In Lebanon, following the return to school post-COVID-19, 30.7% of pharmacy students experienced severe to extremely severe depression [18]. Similarly, a study among male medical students at the University of Bisha found a depression prevalence of 26.8% [19], while a systematic review across 13 Middle East and North African countries reported a pooled prevalence of 33.03% among healthcare workers between 2005 and 2020 [20]. Notably, the high prevalence of depression among PharmD students in our study is concerning, particularly given that earning a professional doctoral degree should offer advantages over a bachelor’s degree. We may suggest that if this advanced degree does not lead to financial gains or career progress, it may be perceived as a burden rather than an advancement. For instance, while individuals holding a PharmD degree in Europe and the United States may apply directly for a Doctor of Philosophy (PhD) program in some universities in Egypt, they are still required to complete a master’s degree first. Additionally, the number of pharmacies in Egypt has grown to nearly three times the global average. Recent estimates show Egypt has more than 75,165 pharmacies, with one pharmacy serving every 1,261 citizens, compared to the international average of one pharmacy per 3,500–5,000 individuals [21]. Due to market saturation, a 2018 cross-sectional survey of 1,500 pharmacists revealed that 55% of participants were considering a career shift [21].

In this study, socioeconomic status emerged as a prominent determinant, with students experiencing financial strain being more likely to report higher depression scores. Specifically, students with “insufficient funds for the whole year” had the highest median depression score, while those with sufficient or balanced funds had notably lower scores. Economic insecurity often creates additional burdens beyond academic pressures. Studies conducted in the United States, including those by Adams et al. and Ryu and Fan, reported a consistent association between financial stress and mental health problems among college students, illustrating that financial stability serves as a protective factor against depression [22, 23]. Furthermore, financial challenges are particularly impactful among healthcare students, who may face higher educational expenses and more extended academic programs than in other fields. The demanding nature of pharmacy education and financial insecurity might contribute to a heightened sense of vulnerability and stress among students [22, 23]. Studies indicate that enhancements in financial aid are positively associated with the retention of first-generation students, whereas escalations in loan debt are directly linked to a higher probability of attrition [24,25,26]. A study revealed that the integration of scholarships with peer advising, structured study groups, and mentorship markedly enhances retention, perseverance, and degree completion rates [27]. A separate study revealed that individualized student coaching enhanced retention by 14% after two years of intervention and elevated graduation rates from 31 to 34% among the participating students [28]. Hence, universities should implement financial aid policies and supportive initiatives to enable low-income and first-generation students to fully engage in opportunities essential for academic success, such as on-campus living and extracurricular participation.

The present findings indicated that the type of university was a significant factor for depression, as students attending public universities reported higher depression scores compared to those at private institutions. Contrary to our results, however, Al-Khlaiwi et al. [29] found that anxiety, depression, and stress were higher among private university medical students in Saudi Arabia than among those enrolled in public universities. Financial burden, instructional quality, student population, future employment prospects, and institutional reputation influence students’ mental health. Recent studies have suggested a greater prevalence of depression, anxiety, and stress among private school students compared with their counterparts at public schools [30, 31]. The COVID-19 pandemic further exacerbated financial pressures on private medical students, while parental behavior and heightened academic demands—such as increasing tuition—have also been identified as potential contributors to deteriorating mental health. Furthermore, a misalignment between students’ academic aspirations and their actual circumstances may amplify stress. Consequently, close examination of student satisfaction and expectations is vital to mitigate stress and anxiety [29].

It is important to note that the factors identified in previous studies may not fully apply to the Egyptian context. For instance, the student loan system is not widespread in Egypt, suggesting that private university students or their families often pay tuition without relying on loans. Additionally, the number of private universities in Egypt has grown steadily, particularly in the field of pharmacy. Reports indicate that enrollment in pharmacy faculties at private institutions has increased consistently over the past decade, with some documenting double-digit annual growth [32]. As the number of private universities rises, admissions chances become higher. These universities may also provide a more supportive environment than public institutions; for example, research has found that e-service quality, interactivity, comfort, and familiarity in private universities were positively related to student satisfaction and behavioral intentions [33, 34]. Although these factors may contribute to lower depression rates among PharmD students in private Egyptian universities, improvements are still needed. Previous work shows that public and private universities often fail to adopt student-centered teaching methods, incorporate quality assessment, and offer graduate job placement services [35].

In this study, demographic factors such as sex, residence (urban vs. rural), family involvement in healthcare, and prior career planning did not show significant associations with depression scores. For instance, no notable difference was observed between male and female students, indicating that these variables were not substantial predictors of depression levels in our analysis. This lack of sex-based disparity contrasts with findings from previous studies, where female healthcare students often reported higher levels of depression and anxiety due to perceived dual burdens of academic and familial responsibilities [36, 37]. Another study conducted in South Asia showed that undergraduate females are at increased risk of depression compared with males [38]. Pacheco et al. [39], in their meta-analysis, showed that females were at increased risk of depression.

Variables such as urban or rural residence and family involvement in the healthcare sector showed no significant correlation with depression scores, indicating that depression in this population is mainly independent of location or familial professional background. This lack of difference based on residence and family healthcare involvement may reflect the relatively homogeneous academic and social stressors experienced by pharmacy and medical students across diverse backgrounds [40, 41]. The overarching demands of pharmacy education, including rigorous coursework, clinical placements, and high-stakes exams, likely contribute to a uniform stress level for all students [42]. For instance, both urban and rural students face similar academic expectations and limited time for social activities, which may minimize any potential influence of residence on mental health. Similarly, while having family members in healthcare might offer initial familiarity with the field, it does not necessarily alleviate the academic pressures of pharmacy school. These universal stressors likely overshadow any advantage that background familiarity or location could provide.

While previous studies suggest that advanced students in healthcare fields often develop resilience over time, which is associated with decreased depression and better quality of life [43], our study found no significant association between depression levels and academic year. This finding may indicate that pharmacy students face consistent academic pressure across all years of study, perhaps due to the cumulative demands of their training program. Our findings align with the view that academic challenges among pharmacy students remain high throughout their program [38, 44], suggesting a need for consistent mental health support rather than interventions targeted solely at certain academic years.

Strengths and limitations

This multi-institutional, CHERRIES-guided, cross-sectional online survey identified factors associated with depressive symptoms among PharmD students in Egypt using the 21-item BDI. Strengths include an adequate sample (n = 576), participation from both public and private universities across many governorates, and excellent internal consistency of the BDI (Cronbach’s α = 0.929). Important limitations should be noted. First, the cross-sectional design precludes causal inference and prevents establishing temporality. Second, all data were self-reported, which may introduce response and reporting biases; the BDI is a screening instrument rather than a clinical diagnosis.

Third, recruitment relied on convenience and snowball sampling via online channels and in-class invitations, which may lead to selection and coverage biases; consequently, generalizability is limited, and an exact response rate cannot be firmly established. Fourth, pairwise deletion was used for missing data, which can bias estimates if data are not missing completely at random. Fifth, while financial status showed strong associations with depression scores, we did not collect granular information on specific financial stressors, family income, or sources of financial support. Finally, potentially influential psychosocial variables (e.g., social isolation, anxiety, burnout, employment during study) were not measured, leaving room for residual confounding. These constraints should temper the interpretation of the observed associations.